Provider Demographics
NPI:1801461793
Name:IDZAKOVICH, JOHN GERARD JR (NNP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GERARD
Last Name:IDZAKOVICH
Suffix:JR
Gender:M
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:614-722-2000
Mailing Address - Fax:614-722-4541
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-722-4560
Practice Address - Fax:614-722-4541
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029344363L00000X, 363LN0005X, 363LN0000X
OHRN.446630163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical CareGroup - Multi-Specialty
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0452703Medicaid